1.1 Aspirin (acetylsalicylic acid) was the first
synthetic chemical drug. It was manufactured by Bayer in Germany,
patented and put on the market in 1899. Until then treatment in
Western medicine, as in all other forms of medical practice, including
Chinese and Ayurvedic medicine, was very largely based on the
use of herbs supplemented by preparations of metals and occasionally
animal preparations. The preparations in the Herbal of Dioscorides
published in 55AD remained largely unchanged in Western pharmacopeias
until the twentieth century. There was very considerable variation
in the range of herbs available in Eastern countries and their
pharmacopeias reflected this. But apart from such differences,
the aims were the same, namely to use the herbs that were available
for their effects in ameliorating the symptoms of disease.

1.2 In virtually all systems of medicine the claims
made for the efficacy of such preparations in treating a wide
range of diseases and symptoms usually lacked any clear supporting
evidence or a sound foundation. This was reinforced by the tendency,
still found in the Eastern systems of medicine today, to prescribe
a mixture of many different herbs rather than a single remedy.
Quinine (derived from cinchona bark) for malaria, digitalis (from
the foxglove) for heart failure and opium (from the poppy) for
pain relief were exceptions but even their efficacy was only established
after many years of empirical use. Before the introduction of
the National Health Service (NHS) in 1948, the provision of primary
medical care in the United Kingdom was very uneven. Nevertheless,
many doctors were able to find ample time to spend with their
patients. They made many house visits and came to know much about
the families for whom they cared, both medically and socially.
Their principal method of caring for their patients, apart from
using the range of herbal remedies available, was the provision
of what has been referred to commonly as "tender loving care"
(TLC) to aid natural recovery, namely to supplement the "vis
medicatrix naturae"[1].

1.3 The rate of development in Western countries
of new synthetic chemical drugs has increased steadily since the
introduction of aspirin. Western medicine now has an armamentarium
of remedies that provides the means of preventing or curing many
specific diseases and also of mitigating the symptoms of many
more. This has not happened to any major extent in any other systems
of medicine, although new and effective herbal remedies are still
being discovered and are becoming available to complement the
enormous variety of effective synthetic drugs which are now being
used in conventional Western medicine.

1.4 In parallel with the increased availability of
synthetic drugs, there have been remarkable developments in surgery.
These escalated following the development of effective anaesthesia,
which made complex surgery possible for the first time. The range
of feasible surgical interventions has increased dramatically
and offers a new prospect of radical cures or mitigation of many
maladies. There has also been a dramatic increase in knowledge
of the biochemical or molecular origin of many diseases so that
new diagnostic tests have emerged, many dependent upon measuring
the concentration of various chemical entities in the blood stream,
or upon the use of DNA recombinant technology.

1.5 There are however many common diseases, mostly
chronic, for which new drugs and surgical interventions have so
far failed to provide outcomes that are satisfactory for many
patients. Among these are the various forms of arthritis, low
back pain, asthma, some forms of cancer and many more.

1.6 Modern Western medicine is both complex and expensive.
Increasing pressures on an under-doctored National Health Service
(NHS) are now such that the average primary care physician has
very little time to spend with each patient in consultation in
order to offer the attention and 'tender loving care' which were
important therapeutic weapons for his predecessors. When he or
she diagnoses a serious or acute condition known to be amenable
to modern treatment, the patient will usually be referred to an
appropriate specialist, although some such problems can increasingly
be handled effectively in primary care. When a chronic complaint
is diagnosed it is often treated symptomatically with a prescription
drug. Furthermore in a group practice patients may sometimes see
different doctors on each occasion they attend, and thus lack
a close therapeutic relationship with a single doctor. Added to
this is the fact that many conventional medical and surgical interventions,
as well as effective synthetic drugs, and even some of herbal
origin, produce in some patients troublesome and distressing side-effects
which may occasionally even have fatal consequences. Such adverse
reactions are usually less common with complementary and alternative
therapies. The benefit-risk ratio must be taken into account.

1.7 It is not, therefore, surprising that the satisfaction
expressed by many patients with conventional medicine is often
not as good as it was in the past. It is probable that this is
one of the principal reasons why there has been such a marked
increase in the numbers of people who turn to other systems of
medicine or to complementary or alternative medicine to replace
or supplement their conventional medical advice. It is these complementary
and alternative disciplines that we examine in this report.

1.8 Complementary and Alternative Medicine (CAM)
is a title used to refer to a diverse group of health-related
therapies and disciplines which are not considered to be a part
of mainstream medical care. Other terms sometimes used to describe
them include 'natural medicine', 'non-conventional medicine' and
'holistic medicine'. However, CAM is currently the term used most
often, and hence we have adopted it on our Report. CAM embraces
those therapies that may either be provided alongside conventional
medicine (complementary) or which may, in the view of their practitioners,
act as a substitute for it. Alternative disciplines purport to
provide diagnostic information as well as offering therapy.

1.9 This Inquiry was mounted because there is a widespread
perception that CAM use is increasing not only in the United Kingdom
but across the developed world. This appeared to raise several
important questions of substantial significance in relation to
public health policy.

1.10 Before assessing how CAM use could, or should,
influence public health policy, a more quantitative picture of
use in this area would be desirable. However, quantitative survey
data in this area are somewhat patchy and are beset by questions
of definition which are hard to resolve.

1.11 Several professional bodies have attempted to
define CAM. The British Medical Association (BMA) report Complementary
Medicine: New Approaches to Good Practice suggests that although
the term 'complementary therapies' is familiar to the public,
a more accurate term might be 'non-conventional therapies'. The
BMA defines these as: "those forms of treatment which are
not widely used by the conventional healthcare professions, and
the skills of which are not taught as part of the undergraduate
curriculum of conventional medical and paramedical healthcare
courses"[2].
This definition is now unsatisfactory as the use of some of the
therapies traditionally considered to be non-conventional is growing
amongst doctors (although practice varies widely). Some medical
schools are now offering CAM familiarisation courses to undergraduate
medical students while some also offer modules specifically on
CAM.

1.12 Professor Edzard Ernst, who holds a Chair in
CAM at Exeter University, provided the following definition: "Complementary
medicine is diagnosis, treatment and/or prevention which complements
mainstream medicine by contributing to a common whole, by satisfying
a demand not met by orthodoxy or by diversifying the conceptual
frameworks of medicine"[3].
This definition helps to elucidate the aims of complementary medicine,
but it does not cover alternative therapies which do not seek
to contribute to a common whole but which are offered by their
practitioners as an alternative to conventional medicine. A more
encompassing definition of CAM is provided by the Cochrane Collaboration
as: "a broad domain of healing resources that encompasses
all health systems, modalities, and practices and their accompanying
theories and beliefs, other than those intrinsic to the politically
dominant health systems of a particular society or culture in
a given historical period".

1.13 The CAM community has been struggling for fifteen
years to come up with a single definition of CAM agreed by all,
but with no success. Therefore, when setting up this Inquiry we
decided not to begin with a precise definition of CAM. Instead
we began with a list of therapies which we thought were commonly
considered to fall within the field of CAM and issued this list
with our Call for Evidence (see Box 1). Additional disciplines
have subsequently been added in the light of evidence received
(identified by an asterisk in Box 1). In making the list of therapies
we have provisionally grouped the ones we regard principally as
complementary separately from the ones we regard principally as
alternative. While no firm distinction is possible, we regard
the complementary disciplines as those which usually, if not invariably,
complement conventional medical treatment, while the alternative
disciplines are those which purport to offer diagnostic and therapeutic
alternatives to conventional medicine.

1.14 We have heard much evidence to the effect that
we are now experiencing a rapid increase in the use of CAM across
the Western World. There are limited data on the exact levels
of use and much of the information that is available does not
refer to the United Kingdom. However, some surveys have been conducted
and are reviewed briefly below, in an attempt to achieve a snapshot
of existing CAM use. This has helped to inform subsequent conclusions
about the implications this evidence may have in relation to future
healthcare policy.

1.15 Caution should be exercised when making comparisons.
The results of the different surveys reveal a wide range in the
extent of CAM use. This may partly be due to different definitions
of CAM being used, different methods being used to implement the
survey, the population surveyed and the range of therapies considered.
We have therefore provided a brief summary of the specific CAM
disciplines being considered by each survey at the beginning of
each review. It must also be noted that these surveys take no
account of the increasing use by the public of self-medication
through the purchase of conventional over-the-counter remedies
such as analgesics, cough medicines, antacids and vitamins. We
have not attempted to compare in detail the extent of such self-medication
with the extent of CAM self-medication. However, the Royal Pharmaceutical
Society tell us that in 1999 £2318 million was spent on non-prescription
medicine. They also told us that the non-prescription market has
made increasing profits over the past four years for which they
had figures.

1.16 In 1999 Mr Simon Mills[4]
and Ms Sarah Budd at the Centre for Complementary Health Studies
at Exeter University were commissioned by the Department of Health
to conduct a study of the professional organisation of CAM bodies
in the United Kingdom[5].
This was a follow-up to a study conducted on the same subject
three years earlier[6].
It looked at how many people were working as CAM practitioners.
Its results suggest that there are approximately 50,000 CAM practitioners
in the United Kingdom, that there are approximately 10,000 statutory
registered health professionals who practise some form of CAM
in the United Kingdom and that up to 5 million patients have consulted
a CAM practitioner in the last year. Hence there are two considerations
to consider: the number of practitioners and the number of patients.
Patients can access CAM either through professional CAM practitioners,
through other health professionals (e.g. doctors, nurses and physiotherapists
who offer CAM services) or through the purchase of over-the-counter
preparations.

1.17 A telephone survey of 1204 randomly selected
British adults was conducted for the BBC in 1999[7].This survey did not specify which therapies it classed as
CAM; instead respondents were asked if they had used 'alternative
or complementary medicines or therapies' within the last year.
This was followed by an open-ended question asking: 'What specifically
do you or have you used or done?' Therefore the definition of
CAM was left up to the respondent. This survey's results are summarised
in Table 1.

* Percentages of those who had used CAM. It must be noted that
some individuals use more than one therapy and thus the numbers
above do not add up to 100.

1.18 However, this survey did not expand on whether
the treatment was accessed through the purchase of over-the-counter
remedies or through a professional consultation. This survey also
found that the average amount of money each CAM user spent on
CAM was approximately £14 per month with a large proportion
of users (37%) spending less than five pounds per month. The authors
extrapolated this information to the whole nation and estimated
that the United Kingdom has an annual expenditure of £1.6
billion on CAM.

1.19 Another survey[8]
of CAM use in England (not the United Kingdom) used a questionnaire
sent out as a postal survey to 5010 randomly selected adults and
received 2668 usable responses (a corrected response rate of 53%).
This survey asked respondents whether they had visited a practitioner
of one of eight named therapies in the last twelve months. The
named therapies were acupuncture, chiropractic, homeopathy, medical
herbalism, hypnotherapy, osteopathy, aromatherapy and reflexology.
The survey also asked for information on whether respondents had
purchased any over-the-counter, herbal, or homeopathic remedies.
Results showed that 13.6% of respondents had visited a practitioner
of one of the eight named therapies in the preceding 12 months,
and overall 28.3% of respondents had either visited a CAM therapist
or had purchased an over-the-counter remedy. The most commonly
consulted CAM therapists were osteopaths (4.3% of respondents),
chiropractors (3.6%), aromatherapists (3.5%), reflexologists (2.4%),
and acupuncturists (1.6%). Of the respondents, 8.6% had bought
an over-the-counter homeopathic remedy and 19.8% had bought an
over-the-counter herbal remedy. The NHS paid for an estimated
10% of the visits to practitioners but the authors estimate that
£450 million worth of out-of-pocket expenditure was used
on six of the principal therapies (excluding aromatherapy and
reflexology) during the preceding year.

1.20 In their evidence to us the Royal Pharmaceutical
Society discussed a report from 1999 on over-the-counter sale
of CAM preparations prepared for industry by Mintel Marketing
Intelligence (Q 1313). This report found that retail sales of
complementary medicine (herbals, homeopathic preparations and
aromatherapy essential oils) totalled £93m in 1998. A breakdown
of this figure showed that £50m had come from sales of herbal
medicines, £23m from homeopathic medicines and £20m
from aromatherapy essential oils. The report also showed that
these figures were increasing and that the total revenue was up
50% from £63m in 1994. Overall retail sales in 2000 were
predicted to reach £109m and predictions for 2002 were £126m[9].

1.21 These rather limited data seem to support the
idea that CAM use in the United Kingdom is high and is increasing.
This conclusion is supported by anecdotal evidence received from
many of our witnesses including the Foundation for Integrated
Medicine (FIM),[10]
the NHS Alliance and the Department of Health, confirming that
the public are very interested in this area. A glance at any women's
magazine will reveal pages of information dealing with dietary
supplements and alternative medicine clinics.However,
as mentioned earlier, a more authoritative picture is desirable.
Apart from the data discussed above there is little other evidence
available about usage of CAM in the United Kingdom and a comparison
with the extent of usage of self-medication with conventional
over-the-counter remedies would be useful. More detailed quantitative
information is required on the levels of CAM use in the United
Kingdom, in order to inform the public and healthcare policy-makers
and we recommend that suitable national studies be commissioned
to obtain this information. Information from other developed
countries is also relevant.

1.22 In the United States Eisenberg, David and Ettner[11]
conducted two national telephone surveys of two randomly selected
sets of adults, surveying levels of CAM usage in 1990 and 1997
respectively. They questioned respondents on their use of sixteen
'alternative therapies' and defined accessing alternative medicine
as having used at least one of the sixteen therapies (either as
an over-the-counter preparation or through a professional consultation)
within the previous year. The sixteen therapies included several
that we did not include in our Call for Evidence, e.g. mega-vitamins,
self-help groups, imagery, and commercial and lifestyle diets.
Their remit did not include osteopathy which was included in our
Call for Evidence, and which is generally regarded as a mainstream
medical speciality in the USA.

1.23 The results of this survey are shown in Table
2. In both the 1990 and the 1997 surveys, alternative therapies
were used mainly for chronic conditions such as back pain, allergies,
anxiety, depression and headaches. The authors of the survey found
that extrapolation of their results to the entire population of
the USA suggested a 47.3% total increase in visits to alternative
practitioners, from 427 million to 629 million (which was more
than the number of visits to all US primary care physicians).
Out-of-pocket expenditure on alternative therapies was estimated
at $27.0 billion in 1997.

Source: two nationally representative random household telephone
surveys. Percentages of the total sample population (1539
for the 1990 data; 2055 in 1997). Table shows selected figures relating to the top
five therapies based on the 1997 survey, plus (for comparison
with United Kingdom statistics) figures for homeopathy and acupuncture.

1.24 A national postal survey of 1035 adults which
was designed specifically to find out why patients use CAM was
conducted in the USA in 1998[12].
The survey asked about respondents' need for control over their
own health; their philosophical orientation towards religion,
spirituality, mind and body; their belief in the efficacy of conventional
medicine and their general health and demographic statistics.
A multiple regression analysis was then used to identify predictors
of alternative healthcare use. The most significant predictor
was higher educational status, followed by overall health status.
Chronic health problems such as anxiety, back problems, urinary
tract problems and chronic pain were each also significant predictors
of CAM use. Apart from health and social status the only other
three significant predictors of CAM use were: being 'culturally
creative'; having a holistic philosophical approach to life; and
having had a 'transformational experience'. The author takes the
view that dissatisfaction with conventional care was not the major
factor leading to the use of CAM. He suggests that as well as
being better educated and in poorer health, most users of CAM
access these therapies because they find them to be 'more congruent
with their own values, beliefs and philosophical orientations
towards health and life'. However, it is worth noting that Astin
never asked the critical question: " Has conventional medicine
worked for you?" in his survey, even though he was assessing
why people turned to CAM. The cost of conventional medical treatment
in the USA may also have been another factor.

1.25 The BBC survey of CAM use in the United Kingdom
also asked respondents who had used CAM what their main reason
was for accessing CAM medicines or therapies[13].
Results are shown in Table 3.

1.28 It would be useful to have more research on
why the public are increasingly using CAM in their healthcare
regimes. At the moment the reasons are unclear, but the answer
to this question is important as it may have implications for
the NHS, conventional healthcare practitioners and CAM practitioners,
who wish to meet their patients' needs more comprehensively.

1.29 This report does not consider the clinical efficacy
of particular products or therapies except insofar as evidence
is available to inform policy. We shall return to our reasons
for this later in the report.

1.30 Whatever the reasons behind the popularity of
CAM it is clear that there is an increasing number of patients
and practitioners who are each involved in this area of healthcare.
It is this high level of public interest that has prompted our
Inquiry, raising important public policy questions that we have
been charged with considering:

(i)

In an age where conventional medical research is advancing rapidly with major benefits for patient care and increasing life expectancy, why are people using CAM and for what are they using it?

(ii)

Since most statutory controls pertain to conventional medical and other healthcare practitioners and their relevant organisations, are current regulations adequate to provide a safe service for patients using CAM?

(iii)

Does current medical training prepare doctors, nurses and others to answer patients' questions about CAM? Do they have enough information? Should their training include familiarisation with CAM?

(iv)

How well developed is the training of CAM practitioners? Are appropriate structures in place to support high-quality training? Are proper codes of practice being developed? Are appropriate accreditation processes in place to protect the patient? Are issues of Continued Professional Development being considered?

(v)

Is the state of CAM research adequate? Is appropriate research being carried out to investigate efficacy and to ensure that patients are receiving safe, effective treatments? Are current research methods appropriate for CAM research? Is research funding available and is the research infrastructure there to support work in this area?

(vi)

Should CAM's popularity among the public result in an increase in NHS CAM provision? If so, how should CAM be delivered? Should it invariably be complementary, perhaps by reference to CAM practitioners by doctors in primary care, or is there any case for the provision of alternative medicine on the NHS? Will NHS reforms change how CAM is provided on the NHS?